Reflecting on the State of Mental Healthcare

Mental health issues have surged at an alarming rate, affecting a vast swath of Americans.

In this episode, David Williams revisits our previous discussions on mental health, exploring topics such as the current state of mental health, its impact on various demographics, the future of care, and how new technology is innovating the mental health field.

This episode is brought to you by BetterHelp. Give online therapy a try at https://betterhelp.com/caretalk and get on your way to being your best self.

As a BetterHelp affiliate, we may receive compensation from BetterHelp if you purchase products or services through the links provided.

TOPICS
(0:42) Sponsor
(1:21) The Current State of Mental Health
(1:56) Changes in the Healthcare Perspective on Mental Health
(8:01) Understanding the Scope of the Mental Health Crisis
(9:39) How Mental Illness Affects Lifespans
(15:15) The Role of Telehealth in Mental Health Care
(16:00) Inspiring Guests on Mental Health
(16:23) Mental Health Concerns for Younger Generations
(18:00) Revolutionizing Mental Health in the Black Community
(20:05) Has the Public's Understanding of Mental Healthcare Changed?
(24:04) How New Technology is Improving Mental Health Treatment
(24:30) Should Employers Pay for Mental Health Services?
(26:12) The State of Mental Health with Gen Z
(28:15) The Lack of Access to Care for Mental Health Emergencies
(30:44) Conclusion

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CareTalk is a weekly podcast that provides an incisive, no B.S. view of the US healthcare industry. Join co-hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they debate the latest in US healthcare news, business and policy.

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Transcript

0:00

there's a mental health crisis in America and around the world. The pandemic made matters worse, but post -COVID we still haven't recovered. Gen Z's struggles are the most visible, but literally every generation and demographic is badly impacted. Fortunately, many healthcare providers, entrepreneurs and activists are answering the call, bringing their expertise, technology and organizing skills to the battle. We've spoken with many of them on the show over the past few years, and we pulled together this compilation to help them tell the bigger story. This episode of Care Talk is brought to you by BetterHelp. If you've been thinking about starting therapy, there's never been a better time to give it a try. BetterHelp offers online therapy that's accessible, flexible, and tailored to your needs. Whether you're dealing with stress, anxiety, or just looking for personal growth, BetterHelp connects you with licensed therapists who can support you on your journey to becoming your best self. Never skip therapy day with BetterHelp. Visit betterhelp .com slash care talk. to get 10 % off your first month and take the first step toward improving your mental wellbeing. That's betterhelp, H -E -L -P dot com slash care talk. Welcome to Care Talk, America's home for incisive debate about healthcare business and policy. I'm David Williams, president of Health Business Group. We're taking a break from our regular programming this week to highlight the importance of mental health. Let's kick off this episode with a look at the current state of mental health. featuring Brad Kitteridge and Doug Nemechek from Brightside Health on opening the front door to digital mental health, Christina Minnelli, who's building a better mental health system at Quartet Health, and Rocco Caniglio talking about long -term mental health solutions. What's changed from a health plan perspective that you and Cigna and others united are leaning in to this as a category for care and for support? I'm a psychiatrist, and so I have been paying attention to this my entire career, right? And the last 20 of that have been with the health plan. I think the difference today is to, as Brad mentioned earlier, there's a decrease in the stigma associated with this. And we now have more of the data and the research that really shows not just that costs are higher and people do worse from a holistic health perspective, if they're not getting their emotional wellness and behavioral health needs met, but that we can actually impact that by providing appropriate and timely mental health care and substance use care, and that those individuals are gonna be more productive at work, they're gonna be more productive at home, able to take care of their families and more productive in their community as well. That's right. And I think just to add on to Doug's prior point, if we look historically at studies and the best estimates of the proportion of mental health practitioners who are practicing measurement -based care and actually collecting data on how patients are progressing through care and whether they're actually improving, it's unfortunately been extremely low. Sub 20 % for sure, and perhaps even sub 10 % of practitioners consistently doing that. And if we're not measuring outcomes, we're flying blind. We have no idea whether care is working for a given individual across a population or different types of interventions for the right people. And so in many ways, the industry has sort of stagnated in this sort of perception of more art than science. And that's held back our opportunities to lean in and collaborate together to actually develop better, more impactful programs that are not only gonna help people get access to care and fill appointment slots, but actually get benefit from that care and a measurable impact on both the clinical and financial side. So by starting to, as a company and as an industry, make sure that we measure outcomes consistently and thoroughly across everybody we treat allows us to ensure our care model is effective, allows us to demonstrate to partners like Evernorth that our care is effective and to lean in to build and develop new programs that just haven't been possible before. without that foundation of real data to inform them. I wanted to ask you about the pandemic, which seemed to really radically boost the incidence of mental health problems, especially for younger people. Haven't heard an update on that. What are you seeing in terms of the pandemic and its lasting impact and how that's affecting just sort of the overall amount of mental health care that's required? Yeah, I think the pandemic gave us a couple lessons. One is that absolutely every one of us was impacted enough by stress and it allowed us all to help decrease that stigma we talked about before. I'd start talking a little bit more. We saw huge increases in demand for outpatient behavioral health care and resources. And I think a lot of people thought that would go away when the pandemic ended. But we haven't. That has not happened. We've continued to see, you know, even this year, another 10 to 15 % increase in the number of visits that people are getting. And that's more people accessing behavioral health care, as well as those that are accessing care, using it more than people did on average prior to the pandemic. The other lesson from the pandemic that I think was really important is that it forced us to start to look at different ways to deliver. behavioral health care because we couldn't go to the doctor's office anymore and couldn't make those trips. And so that development of digital care and virtual care that makes it more convenient for individuals. They don't have to take a half a day off of work and drive all the way across town to go see a therapist. They can do it from home or from their car or wherever they're at. And the privacy piece of that, and especially in smaller areas where people still, because of the stigma, might not want their car seen in the parking lot at that, where that therapist's office is. All of that goes away with these new digital and virtual care platforms, and that's helped a lot. So we continue to see demand continue to increase and new innovative ways to deliver care. Is that demand across every age? category or is it primarily in certain subsets? mean, obviously, being since the invention of the like button, know, self harm in teens has as rocketed. There's obviously a lot of a lot of, you know, undiagnosed anxiety and depression among surviving seniors. I there's a are there particular categories or do you see it across the board? Well, we've seen increase in demand across the board at all age groups. But some stand out. So when we think about adolescents, adolescents, we've seen some of the biggest increases in demand for mental health care. Young adults, those 20 to 26, Large increases in the number of suffering from anxiety, depression, substance use issues, and seeking care. We've seen adolescent suicide rates really continue to increase across the board. And so really that demand, and we start looking at How do we get more care and more services to them? And again, using digital, using other means and innovative programs to engage them the way that they want to be engaged and are willing to be engaged to access care really important. But we're seeing that across all age groups. So how do we think about how big of an issue this is? I mean, we talked about how everybody knows something or maybe you know somebody or maybe yourself that's affected. Is there a way to get a handle on how big of an issue maybe mental health is overall and then SMI within, you know, within the US? Yeah, absolutely. So it's estimated and these are recent stats that more than one in five US adults live with a mental illness. And if you add an addiction, you can imagine how that how much larger that is. It is alarming to know that over half of adults with mental illness go untreated. Completely untreated. And the impact of mental illness on our kids is staggering. So almost half of adolescents have had a mental health issue. And adolescent suicide is the second leading cause of death in that age group. The first leading cause of death for kids age 14 and 15. It's really a huge issue. And why does this matter? It really affects everyone. It impacts productivity at work. It impacts employment rates. Individuals with SMI oftentimes are out of work. It impacts lifespan. Individuals with SMI can live an average of 15 to 17 years less than average adults. There's an impact on education. Kids with mental health issues are two times more likely to drop out of high school. So there's so many impacts. There's economic, there's impacts on vitality, lost earnings, and on our communities and our families. So one of the striking things you mentioned is the impact on lifespan. And of course, when you hear about things like, you know, heart disease, diabetes, certainly that affects people at different ages, but a lot of times it's a matter of somebody who's older by the time they really have that. talk about a 14 or 15 year old, you know, with a suicide and, you know, you're taking 80 years off of somebody's lifespan when you do that. So the impact of each one of these things, not just devastating within the community, but measured just in terms of, and to the family, but measured just in terms of lost. years of life is just very, very striking and makes it all the more important to do something about it. What is your sense of the impact that we had from the pandemic? You know, there's a lot of discussion about what the impact was, especially on adolescents. Yeah, I would say, so the stats I gave are kind of during or post pandemic. You know, pre pandemic, we'd say one in 10 adults had a mental health issue post pandemic one in five. I mean, it really, the numbers have doubled, tripled. So it really is an issue. And while lots of sort of new entrants in the space are available now, and there has been relaxing of policy and procedures, which has helped to provide access to care and solve a little bit on the supply side. I'd say that the demand side is going up faster than the supply side. And that's one of the big issues. Got it. So let's talk about opportunities for innovation because we can sit here and lament the problems and say, this isn't this a problem. Yeah, it sure is. But what to do about it? Where can we innovate? Sure. So there are a lot of opportunities to innovate in mental health. And as I said, with the onset of the pandemic, we did get a lot of new entrants in the mental health space. Some may say too many because there's a lot of point solutions out there. But when you look at really sort of systemic change, in particular, I would say, in dealing with the seriously mentally ill, because this is where I'd say we have the biggest challenge and the biggest opportunity. So a couple of areas to innovate. And by the way, I will share, I think some of these innovations, the behavioral health industry can borrow from the physical health industry. So we talked about kind of, my journey from physical health, behavioral health, social care, I really see an opportunity to leverage things that have worked on the physical side of healthcare, in behavioral healthcare, in particular with the seriously mentally ill population. So first of all, one of the big issues in behavioral healthcare, and in particular, very acute with the seriously mentally ill, is our fragmented delivery system. So physical health doesn't talk to behavioral health, it is hard to get access to an appointment, It is hard to get to ensure that the patient even made it to the appointment. It's hard to get the follow -up notes on the physical health side. In behavioral health and in particular in patients with serious mental illness, it is important to treat the whole person. So in order to do that, we've really got to bridge physical health, behavioral health, and also have hybrid delivery models that include bricks and mortar and virtual care. The opportunity to innovate here is really to leverage multidisciplinary care teams, virtual and on the ground care delivery, and also tapping into other services that aren't traditionally paid for by the behavioral health care system. That's one area to innovate for sure. Second, it's really hard to engage patients with moderate to severe mental health issues. Very hard to engage. It requires new models of care. It's not going to be one size fits all. And by the way, people with moderate to severe mental illness, this is not just a Medicaid issue. It's not just a Medicare issue. It crosses all lines of business, all walks of life so that we need new models of care, not one size fits all. Digital tools may work for some. Peers on the ground in their home may work for others. And in most cases, it's a combination. So second area to innovate is really around patient or member engagement and using all the tools that we have available to us. The third place to innovate, and this is a big one, is really around getting aligned incentives and payment models. So this is gonna require models that reimburse for services outside of just behavioral healthcare. You yourself said, David, that many folks with physical health issues often have a behavioral health issue. That is very true. Therefore, when we think about behavioral health, in particular those with moderate to severe mental illness, we need models of care that reimburse for physical health, behavioral health, and for some of these additional services like peers that are typically not reimbursed. And we also need to measure success against total cost of care. Because once you treat a behavioral health need, you will also see likely a benefit on the physical health side of the house with reduced hospital admissions, with better adherence to medication, use of lower cost patient settings. So really it's important to look at total cost of care when you're looking at in particular, the moderate to seriously mentally ill. I think we're behind the curve on telehealth as generally speaking for healthcare. And You know, I think the pandemic forced some of that upon us, which, which I guess could be part of a silver lining to it. So I think, but I don't think that that necessarily replaces in -person visits and some of the value that you can get from some of those in -person visits, even in mental health. think mental health is an obvious place where you can use telehealth a little bit more than you might be able to in other specialties where, you know, many other specialties need to be more hands -on. But we always viewed telehealth as a tool. and the tool belt, like a binary, are you telehealth or are you in person? Next up, we'll hear about the impact of the pandemic on mental health care from entrepreneur, Dina Bravada. And we also have a couple of celebrities opening up about their own experiences and sharing the stories of people who inspire them. That means Courtney B. Vance talking about black mental health and former Congressman Patrick J. Kennedy with his profiles of mental health courage. How are the kids doing? How about mental health for kids? How's that gone? I've heard a lot of concerns and maybe split it out by age group, because it's not just kids versus seniors. Yeah. I think that, and I hope that this will not be news to people. I think that there is now a light that is being shown on really this mental health, like epidemic, you hate to use that word these days, for kids and teens. So the rate of growth of mental health spending among adult populations was about 13 % between 2021 and 2022 for kids. for pediatric populations, so that's 12 and under the rate of growth last year was 23%. And for teenagers, it was 18%. So, and the actual spend on those kids is higher. So it's not quite double, but almost. And so why is that? I mean, they're little people. Why aren't their bills smaller than for adults? And experts in this area really corroborate this finding, which is that kids are presenting later in their course of disease. Therefore, they're requiring more intensive therapies. often they're actually requiring hospitalization. So a lot of those factors that we talked about earlier that are driving costs, we see that in particular in pediatric and teen populations. You've talked about also kind of revolutionizing mental health in the black community. What would that actually take? So we're not just talking about incremental improvements. Well, I don't know technically what that would take because the medical industry is shifting. Doctors are having more and more on them. come in with the same amount of debt. And in order to take care of that debt, they have to service the numbers. so maybe they don't have time to actually do, so tell me about what's going on. How are you doing? They don't have time to do that. And so the pressure's on them. I would have to say that it's a huge issue. that really has to do with taking care of people. And in order to do that, doctors need to be taking care of themselves so that they can afford to have the, they can afford to take care of, you know, the one -on -one and to have a relationship with their patients. And they can, and they, and also probably they need to be schooled about, in the medical profession about their bedside manner, how you actually talk to people. and engage with people that are different from yourself. And, you know, they may approach when a Black person comes in, they don't know how to talk to them. And so they are, maybe they're little afraid, a little put off, in which case the person of color who's a patient just is like, I don't want to go back to that person, they don't like me. And it's that ephemeral. It's a relationship, it's a marriage of sorts. doctor -patient relationship as opposed to a number. It's looking at things a different way. And the doctors, students, when they come out of medical school, they're probably being taught the same way. And the whole idea of the doctor -patient relationship, it's a relationship. Do you think we've really, that the public's understanding has really changed about the public? of mental health being integrated into physical health, or do we still have a lot of work to do there? Well, we have a ton of work to do there because frankly, most people don't avail themselves of mental health and addiction services till they're stage four illnesses. And that's principally because one, stigma's still alive and well, and two, none of us want to walk that, kind of those eggshells to tell the person we love that they're in trouble. until it becomes really obvious when in fact what we need to do is get in there early as if it were cancer, cardiovascular disease and say, listen, this is gonna be a lot easier for you to deal with if you start dealing with it now. We haven't had those conversations with our loved ones. And in this book, Profiles of Mental Health Courage, I not only tell the stories of these 12 courageous people who tell everything, but they had me talk to their parents, their brothers and sisters, their kids. their therapists, their friends and colleagues at work. They really had me talk to people frankly that they don't talk to anymore because their illness has so isolated them. This book is different in that it includes all the people around the person, including, as you know, John, my cousin Mark McMurray. His son, Harry, died of suicide at 23. The first time Mark really talked about his son's suicide was when I interviewed him seven years after Harry had died. about this and Mark was, you know, very full of trepidation, should I do it? Once he got in, he was, it was cathartic for him, which only proves the point that we need to open up and talk about these things. Then he had me talk to Harry's brother, his other son, Belton, and Belton said things that Mark had never heard. Then Mark had me talk to Harry's roommate at college. Harry's roommate in college told both Belton and Mark things that they had never heard of. So my point is if we had had a better chance to for everyone to share there may have been a better chance for them to have intervened earlier and more aggressively with Harry Then was the case because they felt like they couldn't talk about that personal business that you know I don't want to violate his privacy that well, and we've got a quiet epidemic That's beginning louder and louder every day of suicide not just in the military, but across society, particularly when you start throwing self -harm and just deep challenge the self -image for young people. mean, it shakes me to hear that, Patrick, but I think it's a critical conversation to your point about the only way we're going to intervene early is to understand early. You know, it is remarkable these illnesses that we wait until they become you know real really sick people and you know the african proverb if you want to save someone from drowning tried making sure they don't fall in the first place we just don't go up straight and we have to going back to my original point shot come up with a new financial model you know all these european countries that have national health systems do so much in terms of social supports for these illnesses early intervention for the services why because it saves them macro costs which by the way they bear because they come from these big you know centralized health systems we have to figure out a way to incentivize those long -term rly and we need partners to be able to do that ultimately this will only work if the financial incentives align with screening earlier but today payers like out use do i really want to know that they need help You know, because they might not be with me in a year from now. That's a kind of defeatist system. We have to fix the system if we're going to help people. The digital health revolution is tackling challenges throughout health care and mental health is no exception. In this final section, we'll hear from three entrepreneurs who are making a big difference. David Koh shares how the Calm app is improving wellness. Sarah Adler of Wave discusses Gen Z specific approaches. And Tamir Aldad of Mindful Care shares his approach to psychiatric urgent care. So you mentioned that the B2C users, the direct consumers have asked that their employers pay the bill, but is there a good rationale for an employer to be managing stress and reducing burnout? Is that something that should be high on their agenda? Absolutely. Thank you for asking that, David. mean, I there's two things. today when employees have a sea of things to choose from, whether it's around your employee systems, choice of menus of benefits from employers today, it's really hard to discern one thing from the other. The way it's presented to you, right? With the app icon and things like that. And so, a lot of times these benefit managers come to us, and we start to talk to them about our product and they're all users of our product. So one that definitely helps in the process when we talk to them. The second is they just want their employees to use the services that they offer so that they find not only is the engagement and the activation really high with us, so they know actually if they offer us as a service, people will actually use it as a benefit. So often... These benefit managers talk to us and say, have all these benefits, but nobody will use them in the company. So we could tout them, but unless we like have the CEO message them or others, they won't use these products. And so many of these benefit managers say mental health is important for us, but we don't know what types of services we should be offering. And so we try to check all these different boxes for them today. And, you know, that's one of the reasons why we also renew at such a high rate with so many of our employers today. How is the mental health of Gen Z? Yeah, it's a good and debatable question. From my vantage point and my expertise, I think it is not great, to be quite honest. I think that Gen Z is really struggling. There are tons of reasons why their generation is just fundamentally different than ones that have come before. Part of that, of course, is social media and being a digital native. Part of that is just kind of the the state of the world these days. And part of that is the fact that Gen Z also for the first time has a language to describe what's happening for them. So I think it's all of these things together that are really creating the very true feeling that Gen Z is what I lovingly call the misery generation. Well, I guess misery loves company. So that's why you started one. That's exactly right. So this is just a huge demand. for behavioral health services in this generation. And supply, as far as I can tell, is insufficient. It's not growing, certainly not growing fast enough. How do we possibly bridge that gap between supply and demand? Yeah, I fundamentally believe that the way to do it is really threefold. It is through better data infrastructure that we're investing in to really understand who needs what care pathway at what time. It's the... acceptance and the proving out of the efficacy of new care delivery models that really leverage lay healthcare workers, like peer counselors and coaches, combined with that data infrastructure and that technology so that we can really kind of pull people who do not need the highest level of care. out from the most intensive and expensive resources. And then thirdly, it is, I think, really an alignment of the financial incentives between the stakeholders, between the patients, the clients, the users, whatever they're calling them, and the people who are actually paying for health care in this country. What is the biggest problem in mental health today? The biggest issue is access to care. We have patients waiting six to eight weeks to see a provider if they have insurance. In that time, patients... their symptoms could worsen, they could be a risk to themselves or risk to others. If they have substance use disorder, it could worsen. So we need to be very cautious and mindful of the fact that if we don't improve access to care, mental health will only get worse. I know a lot about urgent care and I see it, but I never really thought about it for behavioral health, but it's something you offer. What is urgent care for behavioral health? So our philosophy is that patients right now waiting to see a psychiatrist or a mental health provider sometimes go to the emergency room to access care. Going to the emergency room more often than not is inappropriate and our goal is to create an urgent care model where we offer and triage patients to assess their symptoms, the severity of those symptoms and advise them on what the next best step is. So our version of urgent care is similar to the medical version of urgent care where we offer acute same -day next -day treatment. for patients that otherwise would be inappropriate for hospital admission. Why is it so difficult to find a behavioral health provider and why don't they take my insurance? So it's two things. One, the demand is extraordinary. So providers can pick who they want as patients. They don't have to take everyone and they can be quite selective. And unfortunately, reimbursement is very low. So if you do have insurance, clinicians, are properly incentivized. So if they accept insurance, they usually pick those that are higher paying, or if they don't wanna deal with that, then they just accept cash. I wanna talk about social media for a minute, not podcasts, of course, but how is social media impacting mental health? I think it's doing two things. One, people are very informed, very aware, a lot more educated. It's becoming a lot less taboo. So there is... something positive about the increased exposure to knowledge that comes with social media. The risk though is that it creates a very artificial environment where people are comparing lives. That can create a sense of jealousy. It could also be very triggering because a lot of information is at your fingerprint. So we really have to be careful with the consumption, particularly if people are sensitive to triggers and also constantly reframe situations to realize that what looks like reality sometimes isn't on social media. Well, that's it for our special episode of Care Talk focusing in on the massive challenges and emerging solutions in mental health care. Thanks so much for joining us today. Please make sure to come back next week when co -host John Driscoll and I resume our normal schedule. And remember, if you like what you heard or you didn't, please subscribe on your favorite service.